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autism © 2003
Behavioral approaches to SAGE Publications
and The National
Autistic Society
promoting play Vol 7(4) 401–413; 038190
1362-3613(200312)7:4

AU B Y N C . S TA H M E R Children’s Hospital and Health

Center, San Diego, USA

BROOKE INGERSOLL University of California, San Diego,

USA

C Y N T H I A C A RT E R Children’s Hospital and Health Center,

San Diego, USA

A B S T R AC T A variety of techniques grounded in behavioral psych- K E Y WO R D S

ology, and more specifically in applied behavior analysis, have been applied
established to increase and improve play skills in children with autistic behavior
spectrum disorders. This article introduces a set of efficacious methods, analysis;
which range from highly structured techniques to more naturalistic autism;
strategies. It focuses on object play as other authors in the issue discuss behavioral
social play in greater depth. Behavioral techniques that are reviewed
include: discrete trial training, use of stereotyped behaviors to increase
teaching;
play skills, pivotal response training, reciprocal imitation training, dif- naturalistic
ferential reinforcement of appropriate behavior, in vivo modeling and methods;
play scripts, and video modeling. A discussion of expanding behavior play
techniques to teach more complex play as well as training in varied
environments is also presented. References are provided to allow the
reader to obtain more in-depth information about each technique.
ADDRESS Correspondence should be addressed to: A U B Y N C . S T A H M E R , PhD,
Research Scientist, Child and Adolescent Services Research Center, 3020 Children’s Way
MC 5033, San Diego, CA 92123-4282, USA. e-mail: astahmer@casrc.org

A variety of techniques grounded in behavioral psychology, and more

specifically in applied behavior analysis, have been established to increase
and improve play skills in children with autistic spectrum disorders. This
article introduces a set of efficacious methods, ranging from highly struc-
tured techniques to more naturalistic strategies. We focus on object play as
other authors in this issue discuss social play in greater depth. This is by no
means an exhaustive review of behavioral methodologies, but instead a
sampling of often used, research-based techniques.

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Discrete trial training
Perhaps the most well-researched and well-known behavioral technique for
the direct instruction of play behaviors is the discrete trial training
approach. Discrete trial training was developed in the 1960s to target a
variety of specific skills that would increase the behavioral repertoires of
individuals with autism and developmental delay. Discrete trial training
involves breaking down complex skills and teaching each subskill through
a series of massed teaching trials. In discrete trial training, the learning
environment is highly structured and controlled by the therapist. Play
materials are chosen by the teacher, and the child is presented with a clear
instruction for a response, typically the imitation of the therapist’s model
or compliance with a verbal instruction. Acquisition is facilitated by the use
of explicit prompting and shaping techniques and systematic reinforce-
ment contingent upon the child’s production of the target response.
Play responses targeted early in treatment or with lower functioning
children are usually one-step actions, such as rolling a car or pushing a pop-
up toy. When teaching extended play sequences, the teacher breaks down
the sequence into its component parts. For example, ‘putting the baby to
bed’ might include: putting a pillow in the cradle, putting the doll into the
cradle with its head on the pillow, putting a blanket on the doll, saying
‘Goodnight, Baby’, and kissing the doll goodnight. Each individual step is
taught individually and forward or backward chaining is used to link the
steps together in the correct order. Detailed accounts of targeting play skills
using discrete trial training can be found in Leaf and McEachin (1999),
Maurice et al. (1996), Smith (2001), and Weiss and Harris (2001).
Research has demonstrated that discrete trial techniques are effective
for teaching a variety of types of play, from simple object manipulation
(Eason et al., 1982; Greer et al., 1985; Nuzzolo-Gomez et al., 2002; Santar-
carangelo et al., 1987) to complex play themes (e.g. Lifter et al., 1993).
Studies using discrete trial training to increase toy play have found that
newly acquired play skills are maintained over follow-up periods and gen-
eralize to a variety of novel settings (e.g. Eason et al., 1982; Greer et al.,
1985). Nuzzolo-Gomez et al. (2002) found that after discrete trial play
training and conditioned reinforcement of play, preschoolers with autism
were able to initiate appropriate functional play in their classroom. As with
other play interventions, all of the studies also found an inverse relation-
ship between appropriate play and stereotyped or passive behavior, with
increases in appropriate play replacing the previous inappropriate behavior
(cf. Stahmer, 1993).

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Using stereotyped behavior to increase appropriate play
Stereotyped behaviors have been used as reinforcers for a variety of target
behaviors in intervention (e.g. Charlop-Christy and Haymes, 1996; Sugai
and White, 1986; Wolery et al., 1985). Baker et al. (1998) broadened this
application and used the perseverative themes of children with autism to
create the theme for socially appropriate games. A perseverative theme was
identified for each of the three children participating in the study, and that
perseveration was incorporated into a common playground game. For
example, one child perseverated on Disney characters and so these charac-
ters were incorporated into a follow-the-leader game. The inclusion of the
perseverative theme increased the children’s interest in social play and acted
as reinforcement for play. All three children increased their positive social
interactions with peers on the playground. Increases in positive interactions
were maintained in other games and in the absence of an adult. This
approach was replicated with younger children with autism playing with
siblings (Baker, 2000). Perseverative behaviors, then, can serve as an excel-
lent catalyst for improving play skills in children with autism.

Pivotal response training

As behavioral techniques have evolved, researchers have begun to develop
more naturalistic behavioral methods. Naturalistic behavioral methods typi-
cally incorporate toys or other materials found in the child’s natural settings
as stimulus items (e.g. Koegel et al., 1999). Often, adults systematically
arrange the environment in a way that elicits specific behaviors from the
child and allows teaching opportunities to occur within the context of
interactions in the natural setting. One method that has bridged the gap
between highly structured discrete trial training (which typically uses
analog or drill-oriented teaching) and very naturalistic methods such as
incidental teaching (which is highly dependent upon the environment and
the child’s actions for each teaching opportunity) is pivotal response
training (PRT). This method grew out of discrete trial training and can be
used in a structured or naturalistic format. Pivotal response training is
specifically designed to increase a child’s motivation to participate in
learning new skills. Pivotal response training involves specific strategies
such as (1) clear instructions and questions presented by the therapist, (2)
child choice of stimuli (based on choices offered by the therapist: Koegel
et al., 1987), (3) interspersal of maintenance tasks (previously mastered
tasks: Dunlap, 1984), (4) direct reinforcement (the chosen stimuli is the
reinforcer: Koegel and Williams, 1980), (5) reinforcement of reasonable,

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purposeful attempts at correct responding (Koegel et al., 1988), and (6)
turn taking to allow modeling and appropriate pace of interaction.
Pivotal response training has proven to be a naturalistic training method
that is structured enough to help children learn simple through complex
play skills, while still flexible enough to allow children to remain creative
in their play. An example of using the specific steps of pivotal response
training to teach symbolic play might be as follows. A child may choose to
play with a set of toy cars (choice). The child is then given a block and asked
‘What can we do with these toys?’ (acquisition task). The child is expected
to use the block in a symbolic manner such as to ‘wash’ the car. If the child
does not respond, the therapist would model the symbolic behavior (turn
taking). The block would then be returned to the child. If the child still does
not respond, a new toy would be chosen, or the therapist could assist the
child. When the child does respond, the entire set of cars would be given
to the child to play with in any manner he/she chooses, thus reinforcing
the new behavior. This may include using the toy in a stereotyped manner.
The child can be reinforced for single or multiple step play. The therapist
has the opportunity to model more complex play and provide new play
ideas on his/her turn. A more detailed description of using pivotal response
training to teach complex play skills can be found in Stahmer (1999).
Research indicates that children with autism who are developmentally
ready to learn symbolic and sociodramatic play skills can learn to engage
in spontaneous, creative play with another adult at levels similar to those
of language-age matched peers via pivotal response training (Stahmer,
1995; Thorp et al., 1995). In addition, social behaviors such as positive
responding increase after play training. Generalization to new toys and new
adults is also impressive and these behavioral changes remain stable over
time (e.g. Stahmer, 1995). When rated by naive observers for creativity,
spontaneity, and ‘typical’ play, children with autism improved significantly
after pivotal response training play training; however, their play remained
qualitatively distinguishable from the play of the typical children (Stahmer
et al., 1994). One area of difficulty for the children that continued after
play training was play with another peer, which did not improve. It seems
that specific interaction training is needed to increase play with peers (see
Yang et al., this issue).

Reciprocal imitation training

A variation on the pivotal response training procedure for teaching play
skills is reciprocal imitation training (RIT). Reciprocal imitation training
was developed to teach spontaneous imitation skills to young children with
autism in a play environment; however, this intervention technique has also
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been shown to increase pretend play actions (Ingersoll and Schreibman,
2002). Reciprocal imitation training is designed to encourage mutual or
reciprocal imitation of play actions between a therapist and child. This pro-
cedure includes contingent imitation in which the therapist imitates actions
and vocalizations of the child (e.g. Klinger and Dawson, 1992), linguistic
mapping, in which the therapist label the actions that he/she and the child
are simultaneously performing (e.g. Warren et al., 1993), as well as pivotal
response training strategies such as: child choice of stimuli, direct re-
inforcement, reinforcement of reasonable, purposeful attempts at correct
responding, and direct prompting of the correct response.
Ingersoll and Schreibman (2002) found that very young children with
autism learned imitative pretend play with an adult using this procedure
and this play generalized to novel settings, therapists, and materials. Several
of the children also increased their spontaneous use of pretend play. In
addition, the children exhibited increases in social behaviors such as co-
ordinated joint attention after reciprocal imitation training, suggesting that
both the imitative and the spontaneous play had taken on a social quality.

Differential reinforcement of appropriate behavior

Researchers and clinicians struggle with the development of methodolo-
gies that will increase play skills across settings and minimize the need for
prompting. Generalization and independence in play have remained elusive
for many children with autism. Although several studies report generaliza-
tion and spontaneous use of play skills acquired through discrete trial
training or pivotal response training techniques (e.g. Eason et al., 1982;
Greer et al., 1985; Ingersoll and Schreibman, 2002; Stahmer, 1995), many
families and therapists continue to struggle with teaching individuals with
autism to sustain play and leisure activities over extended periods of time.
One such strategy developed specifically to address these issues is the dif-
ferential reinforcement of appropriate play behaviors (DRA).
In this technique, the therapist monitors the behavior of the individual
with autism in repeated intervals. If at the end of the interval the individual
with autism is playing appropriately, he/she is reinforced with a primary
(edible) and/or secondary (praise, physical touch) reinforcer. If at the end
of the interval the child is playing inappropriately or is unengaged, he/she
is prompted to return to the task and receives no reinforcement.
Although this strategy appears to have strong methodology based on
applied behavior analysis, studies of the effectiveness of a differential re-
inforcement of appropriate behaviors schedule for increasing appropriate
behavior have been mixed. Nietupski et al. (1986) reinforced developmen-
tally delayed adolescents on regularly scheduled intervals for engagement in
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several previously acquired leisure activities that they only engaged in with
direct supervision. Results indicated that the participants engaged in sus-
tained episodes of play behaviors even after reinforcement was discontinued,
and this increase was evident after 4 months without reinforcement.
In contrast, Santarcarangelo et al. (1987) found that a differential
reinforcement of appropriate behaviors procedure was ineffective at increas-
ing rates of appropriate play in two young children with autism, and that
increases in appropriate play were seen only after direct play training. This
finding suggests that differential reinforcement of appropriate behaviors
procedures may be effective for maintaining extended periods of play
behaviors previously acquired through direct instruction, and may be most
effective for developing appropriate play behavior when combined with
other techniques.

Self-management training
Self-management has been posited as an additional option for teaching
children with autism to increase independence and generalization without
increased reliance on a teacher or parent. Self-management typically
involves some or all of the following components: self-evaluation of
performance, self-monitoring, and self-delivery of reinforcement. Ideally, it
includes teaching the child to monitor his/her own behavior in the absence
of an adult. Stahmer and Schreibman (1992) used a self-management treat-
ment package to train three school-age children with autism to engage in
increased levels of appropriate play. These children displayed very little
independent appropriate play before training, and typically engaged in
inappropriate or self-stimulatory behavior when left on their own. With
the introduction of the self-management training package, the children
increased their appropriate play in both supervised and unsupervised
settings, and across generalization settings and toys. Behaviors maintained
after 1 month for two of the children. Decreases in self-stimulatory and dis-
ruptive behaviors were maintained in the unsupervised environments.
Newman et al. (2000) have extended self-management research by
using this technique to help children with autism vary their play respond-
ing, thereby reducing perseverative play. Three preschool-age students
learned new activities using favorite toys that typically elicited persevera-
tive play. Children were prompted to engage in new behaviors with the toys,
and were asked to take a token whenever they displayed a variation in the
target behavior. All three children exhibited increases in variability of play
after self-management training, with the behavior maintaining at a 1 month
follow-up. The authors found this to be a promising method of increasing
the variability of play in these children. Self-monitoring procedures have
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also been used to increase social initiations while reducing disruptive
behavior (Koegel et al., 1992) and to increase independent interactions
with typical peers (Shearer et al., 1996).

Invivo
vivo modeling and play scripts
Another method of play training based on the principles of behavior
analysis is modeling. Modeling research has shown that individuals with
autism can learn new behaviors through the observation of predictable and
repeated sequences. In vivo modeling techniques, which use live models,
have been effective in teaching children with autism various developmental
skills, including labeling (Charlop et al., 1983) and following one-step
commands (Egel et al., 1981). Additionally, in vivo modeling has been
shown to be effective in teaching children with autism appropriate play. For
example, Tryon and Keane (1986) used modeling to increase independent
play in children with autism. More recently, Jahr et al. (2000) used and
compared two in vivo modeling procedures to teach children with autism
to initiate and sustain cooperative play. In one approach, the children
observed two models engaging in scripted episodes of cooperative play,
following which they took the place of one of the models while the play
episode just viewed was repeated. The second approach mirrored the first
except that the children were required verbally to describe the modeled
play episode before they took the place of one of the models. Results of the
study indicated that the verbal recital of the scripted play episodes was a
necessary component in the children’s acquisition of play skills and gener-
alization of those skills across play partners.
In another study utilizing live models and scripted play episodes, Gold-
stein and Cisar (1992) used sociodramatic play scripts modeled and taught
by adults to increase sociodramatic play and social communicative inter-
actions in children with autism. The investigators taught three play scripts
to three triads of children, each including one child with autism and two
typical classmates. Play script training involved modeling and teaching each
child a role, and scripts included both verbal and non-verbal behaviors.
During training, token reinforcement systems were used to deter off-task
behavior when necessary. Results indicated that the children with autism
were able to learn the play scripts and engaged in increased interactive
social play activities following play training.

Video modeling in play training

Video modeling, like in vivo modeling, uses predictable and repeated presen-
tations of target behaviors; however, these behaviors are presented in video
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format, thus reducing variations in model performance. Video modeling
has been shown to improve various skills in individuals with autism,
including conversational speech (Charlop and Milstein, 1989; Sherer et al.,
2001), verbal responding (Buggey et al., 1999), helping behaviors (Reeve,
2001), and purchasing skills (Haring et al., 1987). This medium has also
been claimed to increase vocabulary, emotional understanding, attribute
acquisition, and daily living skills (Zihni and Zihni, 2002). Video modeling
interventions have used both self-as-model and other-as-model methods.
In the first condition, individuals act as their own models, and the video is
edited so that only desired behaviors are shown. The second and perhaps
more prominent method of video modeling employs taping other indi-
viduals, typically adults or siblings, performing target behaviors. Video self-
modeling has been theorized to be more effective than traditional video
modeling because it may promote increased attention from the individual,
although empirical studies have not substantiated this claim (cf. Buggey et
al., 1999; Creer and Miklich, 1970; Sherer et al., 2001).
Applications of video modeling as an intervention technique are now
being extended to teaching and increasing play in children with autism.
For example, Schwandt and his colleagues (2002) used video modeling to
teach 3- and 4-year-old children with autism to increase their play actions,
duration of play, and play-related statements. Following three repeated
presentations of a video clip showing play actions with a specific toy, the
toy was given to the child and the child was instructed ‘Play toy’. Time at
play was systematically increased and differential reinforcement given for
novel play statements and play actions during the intervention period, after
which the videotape presentations were systematically faded. Following the
intervention and fading, maintenance phase measures indicated that the
young children in the study generalized the play behaviors to novel settings
and toys, and some of the children began to generalize play statements that
were shown in the videos (cf. Buggey et al., 1999; Reamer et al., 1998;
Taylor et al., 1999).
In a study comparing video modeling and in vivo modeling (Charlop-
Christy et al., 2000), video modeling was found to be more time and cost
efficient than in vivo modeling and more effective at promoting generaliza-
tion of skills in teaching five children with autism individually assigned
tasks (e.g. expressive labeling of emotions, independent play). Thus, both
video and in vivo modeling may be effective for teaching play skills in
children with autism, who are sometimes described as being visual
learners. The video method may be especially beneficial for children who
initially avoid interactions and for whom effective reinforcers to use in
more traditional behavioral teaching techniques are difficult to find.

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Expanding behavioral play training
The methods discussed have also incorporated parents, peers, and siblings
to teach children with autism a variety of skills, including play. For example,
pivotal response training has been used extensively and primarily in parent
training to increase both language and play in children with autism (e.g.
Koegel et al., 1991; Schreibman and Koegel, 1996; Stahmer and Gist, 2001)
and has also been successfully implemented by siblings (Oke, 1994) and
peers (Pierce and Schreibman, 1997). Self-monitoring has been used to
increase play interactions between children with autism and their non-
disabled peers (e.g. Sainato et al., 1992; Shearer et al., 1996). In vivo and
video modeling have been used with parents and peers, and video
modeling has been used to increase play between siblings (Taylor et al.,
1999). Naturalistic behavioral techniques such as incidental teaching are
commonly used to increase play between children with autism and their
typically developing peers (Kohler et al., 2001). In fact, model preschool
programs, such as the Walden Program at Emory University (McGee et al.,
1999) and the LEAP program in Colorado (Strain and Cordisco, 1994),
have used behavioral techniques to increase play in children with autism
and to train peers to facilitate interaction and play throughout an integrated
school day. Training peers and family members to use these techniques is
one method behaviorists have used to increase generalization and main-
tenance of behavior changes and to increase the intensity and duration of
intervention.
The initial highly structured behavioral play training of the 1960s has
expanded to involve many new naturalistic and creative methods for
teaching play to children with autism, many of which are described above.
Behaviorists have examined methods of altering the environment to
encourage appropriate play and used areas of strength, such as visual pro-
cessing skills, to teach new play skills. This review represents only a few of
the creative methods of altering antecedents and consequences to foster
play.

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